It is the first real day of autumn in Houston. The storm last night brought with it a cold front, as storms in Houston do come late September. In this cool weather, the hospital feels brand new, like an old theater on opening night. The halls are serene and the fields outside tender, as if an audience awaits in anticipation for the curtain to be drawn. The tranquility, however, like the closed curtain, is a façade. Behind every hospital door are hurting people – not waiting to put on a show but waiting for treatment and a return to normalcy. As an art therapist, I specialize in treatment through expression. Often, patients must encounter the deeply personal workings of their own being, and I must be there to help meet them as they are. Thus, my work lies within the great art of presence. 

Author Elizabeth Gilbert, in an interview with Pico Ayer on the On Being podcast, shares her feelings on grief and the end of life at the passing of her wife. When they learned of the terminal cancer diagnosis, Gilbert did not deny that the end would arrive, but she sought to curate the most pain-free, enlightened experience of death possible for her wife. Yet, as they neared the end, the feelings of pain and fear were unavoidable, uncontrollable. In the podcast interview, Ayer asks how the difficult experience of loss might help prepare us for living with what we cannot fix. Gilbert responds, 

“if there is one thing that I, if I had the chance to do it over again, could’ve done differently, would’ve been to let go of that from the get-go — to walk into it in a stance of surrender, arms collapsed, no clipboard, no agenda, no cherished outcome — and to have almost gone limp into it, which is not the same thing as hopelessness, but it is a very powerful stance to take in the wake of something that is bigger than you are.” “To walk into it in a stance of surrender, arms collapsed, no clipboard, no agenda, no cherished outcome”

– these are the decrees I strive to follow in my own work. There is art in good therapy. It consists of openness, honesty, empathy, and humility, all of which can be summed up as the essence of presence. Presence is intimate; it is a shared intention in honor of the connectedness of life. Presence is also paradoxical. Just as it calls for discernment and might, so too does it call for surrender and smallness. At its best moments, therapy care requires simple and complete presence across multiple levels of being: the patient towards herself, the patient towards the therapist, the therapist towards the patient, and the therapist towards herself. Once everyone partaking in the experience realizes they are at a position for wondrous work, the collective outlook shifts. As Gilbert describes, the realization resembles a limpness in the presence of something greater than any of us. 

        In this essay, I will explore the connection between presence and care, and the ways in which witnessing presence allow for a deeper, more intimate care. I draw on the experience of two young, outstanding patients I have encountered in the duration of my time as an art therapist, along with their respective works of art. Through a contemplative comparison of the patient encounters – meaningful displays of art themselves – as well as the physical artworks, I will tie together the ability to be present with the outcomes of care. 

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An Introduction: Therapy in Art

        I work as an art therapist at a public mental hospital in the heart of Houston. My work consists of providing materials for patients, getting to know them personally, and guiding them in artistic expression. The hospital has ten units total for inpatient care, providing 24-hour hospitalization for individuals with mental health issues. Patients range from children as young as five years old to adults as old as seventy. The adult units are located under one main building, which the other patients call the Hell House. The patients needing the highest aid and security are housed in these main building units. Other groups are dispersed throughout the premises in a semicircle, including units for teenagers, tweens, young children, and veterans. When admitted, each person is evaluated to determine the kind of mental healthcare they need based on medical background and expressed disorders. Adults are divided into categories: anxiety and depression, drug addiction and abuse, suicidal tendencies, homicidal tendencies, and veterans. Children and adolescents, however, are divided by age and sex into larger motleys. For four months, three times a week, I have worked part-time at the hospital traveling between units providing group therapy sessions. My weekly schedule includes adults with anxiety/depression and homicidal tendencies, veterans, children, and teenagers. Each unit appears distinct at its surface, but each requires a similar sense of humanity: an openness and dedication to presence in the face of great suffering. 

        It is not easy seeing kids at the hospital. Most of them will be candid with me, tell me about the people they miss and the things they liked to do. They are in here for a variety of reasons, many of which are connected – CPS, abuse at home, bullies at school, violence, drug abuse, suicide attempts, ODs, depression, BPD, eating disorders, learning disorders. Many of these kids  have already been fighting all their lives. It’s not easy seeing them here because it is clear the enormous amount of pain and growth each kid has experienced. When I first began my job at the hospital, I was unsure what to make of all the suffering people I met. I desperately wanted to help, but how? I saw myself as too young, too inexperienced, too overwhelmed. Still, I contemplated. Every week I met new people, listened to their stories, and talked about their artwork. As I continuously gave myself up to these shared moments with patients, I encountered a kind of magic in the work we were doing. By being open, humble, honest, and empathetic, I was being fully present to these shared interactions. My patients seemed to leave art therapy generally happier and calmer, more heard and understood – and I did too. As I work with the mind and the social, I have been challenged and transformed in ways that manifest in my everyday life. By meditating on two powerful young patient experiences and their artworks, I hope to provide a deeper appreciation for the phenomenon of presence in healthcare work. 

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Patient 1: Presence Exhibited 

        Unit 6. Teen girls. When I walk into the unit, every girl is sitting still as the technician gives announcements. She’s new, I think, but she commands the room with the determination of a veteran tech. The kids recognize me when I enter. I work with them once a week, and every week, only about half of the patients are newcomers. I place my bag behind the nurses station and gather my session materials methodically. One girl comes to knock on the glass in front of me. She’s excited for group today, and I smile back through my mask. I announce today’s activity: draw or write about something that is important to you. There is a stack of blank paper and twenty markers – I made sure to count them – for the girls to share. After everyone’s chosen their materials and dispersed to tables with their friends, I walk around and observe. 

        We have a full unit today, maybe twenty or so girls. Ever since the school year started up again, the units have been running consistently at full or overflowed capacity. The experienced technicians tell me that problems at school bring more kids here. There’s three full tables of girls and one straggler at the center table. I go around checking in with each group, introducing myself, asking about their drawings, and listening when I’m given the opportunity. I am not credited to give advice – I do not have a degree or a license to therapize – but I seek to heal through presence and openness. I want the patients to know that I care and want to understand. Today, the girls’ drawings are incredibly detailed. By just a scan around, I notice stick figure families, puppies, flower fields, and anime cartoons, along with the more explicit naked bodies, marijuana joints, curse words, and misshapen sketches. The room has hushed and grown gentle, everyone intent on depicting the importance in their lives. 

        As I browse the room, one paper catches my eye. A pulse monitor, a coal-black heart, a name written in cursive. It is the straggler girl sitting alone with her drawing at the center table. Curious, I approach lightly and introduce myself again. She tells me her name, her age, and returns to her drawing. I watch as she surrounds the pulse monitor with several more hearts in black marker before I ask my question. What is her drawing about? It is intimate, and I know I am asking for her to be strong and open with a stranger. She smiles softly as she speaks. 

        She grew up with her mom, a single mother raising three young kids. A heroin addict. Ever since she can remember, her mom used and abused her and her siblings. She stuck needles up the toddlers’ arms till their apartment choked with the stink of heroin. The girl wanted out as soon as she could. When she turned thirteen, she ran away from home to her boyfriend’s place. His parents took her in as best as they could, also being drug addicted. The two teenagers then made a plan. As soon as they gathered enough money, they would buy themselves a home of their own, away from all the people and places of their childhood. So, they began to grow and sell marijuana. Their biggest buyer was a local police officer who had caught and then befriended them. 

        In a year, the teenagers earned enough cash for a small room at a motel. Finally, a home they could call their own. Yet, the obstacles of the past continued to subsist. Her mom needed money, her siblings needed help, the cop needed weed. And now, there were the additional hurdles. The motel needed rent, the car needed gas, they needed to be fed. She wondered if it would ever be possible to escape. Then, the baby arrived. A few months into motel living, she became pregnant. It was an accident; she knew more than anyone that she couldn’t raise a child. She was only a kid herself. With all her mother’s mistakes in mind, she decided the baby would have to go up for adoption. When Skylar was born, they spent no more than three weeks together. Then, the baby was off to a nice adult couple who owned their own home, raised their own children, and had enough money to take good care of Skylar. 

        I blink back tears. The pulse monitor is the baby, the name in cursive is Skylar, and the hearts are for the child she never got to know. I think of the immense strength she must have to recount and relive these memories with me, a stranger. The paradoxes of life reveal themselves again. To have lived through such pain and fragility and to be so resilient and genuine is a powerful binary to observe in any individual, especially one as young as she. I am drawn to be fully present as we share intimately in her memories. 

        A week later, it is Sunday once more, and I have Unit 6 again. There is a fifty percent chance that the girl is here today, and I suppose the odds were in my favor because there she is, standing in the middle of the room, composition notebook in one hand and pencil in the other. This time, she recognizes me and approaches with her notebook open. She would like to share with me her new sketches. They are penciled film noir-esque illustrations of a young girl with headphones on and hair covering her eyes. She moves through the images alone and downcast, in a bedroom, on a bus, in a field. I realize the girl in the notebook is the girl standing before me, being completely present with herself through the pain and depression illustrated in her artwork. Her face appears older, not resigned in age but wiser, and her gaze seems perceptive, as if she has understood her shift in being. She hands me a blank piece of paper. I flip it over and recognize a lone lotus flower in the center of the page. The color is a jarring contrast; it’s beautiful. Pink petals, green leaves, and a cerulean aura around the petals. According to Binghamton University’s Institute for Asia and Asian Diasporas, the lotus flower is regarded as a symbol of purity, enlightenment, self-regeneration, and rebirth. In Buddhism, the Buddha is often depicted sitting on a lotus flower, as are many gods in Hinduism. As the lotus grows, its roots rise from the muddy waters to produce an exquisite budding flower, symbolizing an overcoming of the material world into enlightenment or utmost divinity (Binghamton University). Thus, the young girl’s drawing of the lotus flower carries innate meaning in its religious symbolism. An image of rebirth bathed in an outline of light, like the artist rebirthing from the pain of her past self and blooming into the glow of her present self. 

        The young girl was able to grow intimately in her work because she first allowed herself to be vulnerably honest. I carry her story closely because she reminds me of the great power of presence that lies within mental care work. As she represents presence exhibited, others have represented presence obscured. I draw from another young patient’s example to reify the value of presence in care. 

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Patient 2: Presence Obscured

        Unit 8. Children’s unit. The pandemonium hits me before I enter, the heavy door barely a filter for the cries inside. I take a deep breath, the power of breathing under stress made clear to me after a year of yoga and meditation. Again, I gather my materials behind the nurses station, behind the safety of the glass walls. There are two weeks until Thanksgiving, and today’s prompt is: draw or write about what you are thankful for right now. There are twenty-five kids here today, kindergarten to sixth grade from all around the greater Houston area. They cheer as I bring out the paper and markers. Markers are prohibited for independent use, and art therapy once a week is a serious treat for the kids. As people start to draw, I begin my routine. 

        At each table, they tell me about their adorable portraits of friends and family, and their papers filled with pretty food and gadgets. As I wander around, one little boy continues to catch my eye. In the span of ten minutes, he has gotten up four times for a new piece of paper. I glance over his petite, hunched frame to see a bright red, exceptionally symmetrical heart. This must be his fourth attempt at creating a perfect outline. He looks up at me and begins to sob. I worry that I’ve upset him, but he crumples up his heart and makes a beeline for the stack of papers. He is not upset at me but at his work. The assignment seems to have dissatisfied, angered, even tortured him. I breathe and remind myself of presence. The young boy and I sit and talk. He yells at me through teary eyes that he misses his mom and wishes to give her a heart, but he cannot make one good enough. I struggle to comfort him with assurances of his mother’s love, of his skillful artistry, and of the infinite amount of paper we have, but his torment carries on. I cannot force him to be present with me, as his loathing grips him in the mindspace of ill feeling. Defeated, I pick the crumpled piece of paper out of the trash and place it in my bag for safe keeping, for now. 

        In the weeks following my conversation with the young boy, I saw him only once more. We worked with symmetry coloring sheets, the kind with half an image printed and half left to draw. By his third attempt, he was enraged and already removed from the present moment. He sought me in his isolation, but it was as if I could not reach him. Once again, no matter what I said or did – printed out sheets, praised his drawing, prolonged art therapy – we remained at a disconnect. I grew frustrated and eager to leave and I, too, fell distant. Like the young girl from Unit 6, moments with the young boy remain with me because they remind me of the importance of presence. We were unable to create intimate, wondrous work because there was no meeting that occurred apart from the detached physical interaction. Perhaps if I was able to meet the boy at a time void of any assignments, we would find openness, connection, and an understanding of the work that needs to be done. For now, I keep his wrinkled heart as a reminder of the heavy lifting in exercising care. 

        In a metaphoric analysis of “heart” and its etymology, cross-linguistic researchers Berendt and Tanita explore connections among uses of “heart” and cultural expressions of the social and emotional. They introduce its usage in English according to the Oxford English Dictionary as, “encompass[ing] all of feeling, understanding and thought. The ‘heart’ in Old English was seen as the locus of thinking which in modern English is equated to the ‘mind’,” the subject of therapy work. The researchers analyze contemporary English usages of “heart” expressions into three typologies: the heart as the locus of rational discourse, the heart as the locus of love and affection, and the heart as the locus of courage. These expressions share the conceptual framework of the heart as an entity or container. When we speak of the heart, we view the image as a container for such emotions, an entity expressing our inner condition. The young boy’s precise construction of a heart can be seen to represent a container of love and affection for his mother, an emotion he can subtly express through the symbolic. The precise strokes of marker forming each layer of the heart further heighten the significance of his creation. 

A Culmination: Medicine in Presence

        The teenage girl was able to grow during the time we spent together because she was present to herself, thus allowing her to be open and present with me as well. The young boy, however, continued to deny himself, instead unavoidably immersing in his own turmoil. In both their artworks, we can visually discern this difference in presence. The boy’s crumpled up perfect heart symbol unveils his inner emotion that he is unable to meet face-to-face. Au contraire, the girl’s lotus flower represents an inner peace, a simple, beautiful depiction that suggests she has met herself as she is. 

        Presence is an intimate paradox. It consists of surrender and strength, both at extraordinary levels of being. As we experience life and its paradoxes, we encounter the play of presence and absence. Presence is the essence of experience because presence is a necessity to any observation. Moments of extreme presence allow us to experience life in its full. In the consideration of healthcare, presence becomes ever more necessary because we are working with human life at its most fragile states. Whether it be on call in emergency medicine, in the pits of the operating room, or with a traumatized patient in the office, care workers consistently exist on the edge of mortality, and presence is the medicine often forgotten. As I continue my job in therapy, I intend to meet myself and my patients where the both of us can and need to be. This is the kindest way to be present, as nothing is owed, nothing is earned, and nothing is asked. Further, outside of art therapy, I hope to be a bearer of presence for all that surrounds me, as I extend work from the clinic into the theater of life – in a stance of surrender, arms collapsed to the program of the present moment.